鼻窦胆固醇肉芽肿24例

目的探讨鼻窦胆固醇肉芽肿患者的病因、发病机理以及治疗方法。方法回顾性总结分析1996年3月至2003年3月经手术和病理证实的24例鼻窦胆固醇肉芽肿患者的临床资料。结果24例患者中，术前诊断为慢性鼻窦炎10例，鼻窦黏液囊肿8例，鼻息肉或出血坏死性鼻息肉5例，考虑可能为胆固醇肉芽肿者仅l例。主要症状有鼻塞(20／24)、鼻漏(18／24)、嗅觉减退(10／24)、头痛(7／24)、眼眶痛(5／24)、复视(2／24)等。鼻窦CT及MRI提示为慢性鼻窦炎、鼻窦囊肿以及鼻息肉和(或)黏膜息肉样变。所有病例均因保守治疗无效而采取外科手术治疗，即鼻内镜术或Caldwell-Luc术，仅l例行鼻侧切开术。23例手术效果良好，随访1年以上无复发；仅l例Caldwell-Luc术后2年复发，再次行鼻内镜术，术后3年未复发。结论鼻窦胆固醇肉芽肿的病因主要有三：含气腔通气受阻、引流障碍、含气腔出血。鼻窦胆固醇肉芽肿似乎与鼻窦慢性炎性疾病关系密切，尤其是鼻窦黏液囊肿。术式的选择应根据病变范围和程度来决定，其原则是彻底清除病变，保持鼻窦通畅引流。     

Cholesterol granuloma of the paranasal sinuses

Cholesterol granulomata of the middle ear occasionally accompany chronic middle-ear diseases with diminished ventilation. In the paranasal sinuses, especially in the frontal sinus, they have occasionally been mentioned in the literature. Disordered ventilation and impaired drainage are decisive pathogenic factors in the causation of cholesterol granuloma. Views remain divided on the source of the cholesterol and on the importance of bleeding in the development of cholesterol granuloma. Two patients with a cholesterol granuloma of the frontal sinus are presented and discussed.     

Image-guided transphenoidal drainage of a cholesterol granuloma of the petrous apex in a child

Cholesterol granulomas of the petrous apex are well-described lesions that originate from chronic obstruction of the air cells in the petrous pyramid. Intracranial surgery, associated with multiple potential complications, has been the salutary action to treat this entity with only two reports of endoscopic drainage of a cholesterol granuloma of the paranasal sinuses. We present the first pediatric patient to be treated by not only endoscopic drainage, but also by the incorporation of computer-assisted image-guided surgery to minimize risk of injury to structures adjacent to the posterior wall of the sphenoid sinus.     

Paranasal sinus development and choanal atresia

BACKGROUND: Although the determinates of paranasal sinus development and sinusitis are not well defined, a candidate factor is blockage of the choana. HYPOTHESIS: Maxillary sinuses ipsilateral to unilateral choanal atresia are comparatively small and have more evidence of sinusitis than do the contralateral sinuses. DESIGN: Retrospective. SETTING: Children's hospitals. PATIENTS: Sixteen nonsyndomic children with isolated unilateral congenital choanal atresia. MAIN OUTCOME MEASURES: Determination of maxillary sinus volumes and mucoperiosteal thickening on preoperative computed tomograms. RESULTS: Maxillary sinuses ipsilateral to unilateral choanal atresia have slightly larger volumes than, and mucoperiosteal thickening that is similar to, the contralateral sinuses. CONCLUSION: These data suggest that maxillary sinus development and sinusitis are independent of posterior nasal ventilation and drainage.     

Ventilation and drug delivery to the paranasal sinuses: studies in a nasal cast using pulsating airflow

BACKGROUND: Although there is a high incidence of nasal disorders including chronic sinusitis, there is limited success in the topical drug delivery to the nose and the paranasal sinuses. This is caused by the nose being an efficient filter for inhaled aerosol particles and the paranasal sinuses being virtually non ventilated METHOD: The objective of this study was to visualize the efficiency of sinus ventilation in a nasal cast using dynamic 81mKr-gas imaging in combination with pulsating airflows. Furthermore, the efficiency of the deposition of radiolabelled aerosol was assessed. RESULTS: Pulsation increased ventilation efficiency of the sinuses more than fivefold and aerosol deposition efficiency more than twentyfold, compared to delivery without pulsation. Furthermore pulsation increased aerosol deposition in the nasal airways by a factor of three. Using pulsating airflow Kr-gas ventilation and aerosol deposition efficiencies increased with increasing sinus volume. Pulsating airflow resulted in a deposition of up to 8% of the nebulized drug within the sinuses compared to 0.2% without pulsation. CONCLUSIONS: The study demonstrates the high efficiency of a pulsating airflow in paranasal sinus ventilation and aerosolized drug delivery. This proves that topical drug delivery to the paranasal sinuses in relevant quantities is possible.     

Cholesterol granulomas in antrochoanal polyps: a clinicopathologic study

The purpose of this study was to investigate antrochoanal polyps with cholesterol granuloma (CG), which is a granulomatous reaction to cholesterol crystals that has been precipitated in the tissue. It is usually associated with chronic middle ear disease, common in the mastoid air cells, less common in the orbit and rarely found in the paranasal sinuses. The aim of this study was to analyze the etiology and pathological findings of antrochoanal polyps associated with cholesterol granuloma. This is a retrospective study of five cases of antrochoanal polyp with cholesterol granuloma, (four males and one female between 15 and 77 years of age) who presented with nasal obstruction, rhinorhea and snoring. The cases were clinically and histologically reviewed. Four patients were treated endoscopically and one by intranasal polypectomy without endoscope. There was no recurrence during the follow-up between 24 to 36 months (mean 31.2 months). Five uncommon cases with antrochoanal polyp with cholesterol granuloma are presented. The cholesterol granulomas consist of fibrous granulation tissue containing cholesterol crystals with surrounding foreign body giant cells. The pathogenesis of antrochoanal polyp with cholesterol granuloma is unclear, and further investigations are needed.     

Effect of irrigation of the nose with isotonic salt solution on adult patients with chronic paranasal sinus disease

In a prospective, randomized, controlled, double-blind trial we compared the effectiveness of endonasal irrigations with Ems salt solution to that with sodium chloride solution in the treatment of adult patients with chronic paranasal sinus disease. Subjects (n = 40) were randomly allocated to treatment either with isotonic Ems salt solution or with isotonic sodium chloride solution. The treatment consisted of endonasal irrigation twice daily and additional nasal spray as required. Nasal endoscopy, plain radiography of the paranasal sinuses, olfactometry, anterior rhinomanometry, and a saccharin-clearance test were carried out on days 1 and 7. Patients recorded rating scales of general discomfort, nasal airway obstruction, agreeableness of the irrigation, duration of improved nasal resistance after each irrigation, and the amount of additional nasal spray in a diary. Nasal air flow was not improved significantly. Subjective complaints, endonasal endoscopy, and radiography results revealed a significant improvement in both groups (P = 0.0001). In comparison, the two groups were not significantly different in outcome. Endonasal irrigations with salt solutions are effective in the treatment of chronic sinusitis, and a significant difference between Ems salt and sodium chloride was not observed. Received: 18 January 2000 / Accepted: 20 July 2000     

Microscope and endoscope-assisted surgery of inflammatory diseases of the paranasal sinuses. Value of the Messerklinger infundibulotomy

Insights into the importance of the infundibulum of the anterior ethmoid bone in the etiology and pathogenesis of chronic paranasal sinusitis, based above all on the studies of Messerklinger, have resulted in a fundamental change in our concept of therapy: the main objective of any treatment must be the restoration of ventilation and drainage of the paranasal sinuses in the region of the semilunar hiatus. Its function in the healing of paranasal sinus diseases parallels the significance of the Eustachian tube for the healing of inflammatory lesions of the middle ear. In many cases, the objective is attained by infundibulotomy, using Messerklinger's technique. Our technique differs from that described by Messerklinger and Wigand: we use the surgical microscope and a self-retaining nasal speculum. It is thus possible to operate with both hands, as in microsurgery of the ear and the larynx. Moreover, the operations can be taught and learned via an observation tube. Since the introduction of this technique which can be extended at any time to complete endonasal surgery of the maxillary, ethmoid and sphenoid sinuses, extranasal operations on the paranasal sinuses have become exceedingly rare. The results have been checked in a newly established paranasal sinus clinic.     

霉菌性鼻窦炎临床诊治分析

目的探讨霉菌性鼻窦炎的诊断分型和治疗方法。方法回顾性分析21例霉菌性鼻窦炎病人临床资料，全组病例均行手术治疗，其中功能性鼻窦内镜手术(FESS)13例、柯陆氏5例、鼻内镜下单纯蝶窦开放术1例、FESS加蝶窦开放术2例。结果21例病人均治愈，且均经术后病理证实。结论霉菌性鼻窦炎以上颌窦多发，蝶窦、筛窦次之、额窦最少，分型以非侵袭性霉菌性鼻窦炎最常见，CT检查是早期诊断的有效途径。疗效预后关键在于鼻窦开放程度、引流通畅与否。     

Nasal symptomatology,obstruction, and paranasal sinus opacity in patients with chronic obstructive pulmonary disease

Conclusion: Patients with chronic obstructive pulmonary disease (COPD) more frequently suffer from nasal symptoms as well as upper respiratory tract obstruction compared with the healthy population. Objective: The relationship between chronic rhinosinusitis and bronchial asthma has been studied in detail in the past. In recent years, a limited number of authors have also studied involvement of the nose and paranasal sinuses in patients with COPD. Methods: This was an observational cross-sectional study with subsequent prospective assessment; 42 patients with COPD were included. The control group consisted of 12 healthy subjects. All patients with a history of rhinitis or rhinosinusitis and patients with previous surgery of the nose and sinuses were excluded from the study. Clinical variables evaluated were nasal symptoms (SNAQ-11 questionnaire), nasal endoscopy, nasal patency (active rhinomanometry), and computed tomography of paranasal sinuses. Results: In the COPD group, there was a higher occurrence of nasal symptoms and pathological findings on nasal endoscopy compared with the control group. The overall nasal airflow was higher in the control group (compared with COPD patients) and the overall nasal resistance was higher in the COPD group (compared with controls). Pathological opacity of one or more sinuses was confirmed in 38% of COPD patients.     

Paranasal sinus aspergilloma: a case report

Aspergilloma, though rare, is a benign condition of the paranasal sinuses affecting young males with reasonable morbidity. Besides diagnosis, optimal surgery and prolonged adequate medical therapy under vigilant supervision is mandatory to treat this condition effectively, We are presenting one such ease of aspergilloma who was appropriately managed.     

Aerosinusitis

Aerosinusitis more frequently affects the frontal sinus than the maxillary sinus and mostly occurs during descent. Sinonasal diseases and anatomic variations leading to obstruction of paranasal sinus ventilation favor the development of aerosinusitis. This Continuing Medical Education (CME) article is based on selective literature searches of the PubMed database (search terms: “aerosinusitis”, “barosinusitis”, “barotrauma” AND “sinus”, “barotrauma” AND “sinusitis”, “sinusitis” AND “flying” OR “aviator”). Additionally, currently available monographs and further articles that could be identified based on the publication reviews were also included. In part 2, diagnostic measures, drug therapy, balloon dilatation and endoscopic sinus surgery are presented, along with a discussion regarding when flight attendants and pilots are able to resume their work. Endoscopic surgery to expand the natural drainage pathways of the affected sinuses with minimal surgical trauma to the healthy mucous membranes is largely successful.     

Nasal obstruction in the adult: is CT scan of the sinuses necessary?

OBJECTIVE: To determine whether CT (computerized tomography) scan of the paranasal sinuses is essential in the diagnosis and medical/surgical management of nasal obstruction. DESIGN: One hundred thirteen adult patients with nasal obstruction but without signs of sinusitis who underwent CT examination prior to surgery, were included in the study. RESULTS: Fifty seven percent of the CT scans revealed a variety of abnormal findings. Of the patients with an abnormal CT scan, surgical planning had to be altered in 16 patients due to significant abnormalities found on the CT scans. CONCLUSIONS: We conclude that CT scan of the nose and paranasal sinuses is an effective presurgical planning tool in patients with nasal obstruction.     

Pathophysiologische aspekte der oberen luftwege: Nase,nasennebenhöhlen,ohrtrompete

Summary The physiopathology of the upper respiratory tract (nose, sinuses, Eustachian tube) is examinated on a double point of view: ventilation and drainage function. The authors put the accent on the importance of the air flow resistance of the nose, the measuring methods (rhino-manometry and plethysmography) and the physiological (nasal cycle), the pathological as well as the therapeutically induced variations of resistance. The interdependance of the nasal and the pulmonary resistances is emphasized as well as the importance of their simultaneous measurement as a valuable mean to assess the operative indications.The nature and the mechanism of the mucociliary drainage of the nose are discussed. The measuring methods (among which an original device developed by the authors: the photooscillography) make evident the noxious effects of some environmental factors or of therapeutic agents as well as in some cases their favorable action. Some pathological disorders may also find an explanation. The physiopathology of the sinuses is centered on their ostiums whose patency is essential for a good ventilation; the authors having prooved that the diffusion was responsible for this ventilation they have developed a new and very efficient method of aerosoltherapy (sonic or vibrated aerosols).The physiopathology of the Eustachian tube has been examinated on 3 points: the pressure equalization function including gaseous exchanges, opening mechanism, quantitative testing of the tubal patency with a new method the sonomanometry by which it is possible to measure the dysfunction state and to assess the mucous or the muscular origin of the obstruction.The biological and physiological mechanisms of the drainage function are exposed together with the diseases connected with tubal obstruction.     

Studies of paranasal sinus ventilation by xenon-enhanced dynamic CT

A new method to determine ventilation of the paranasal sinuses is presented. After insufflation of pure stable xenon into the sinus system via the nasal cavity the gas wash-out is detected by means of quantitative dynamic computerized tomography. The measured time density curves allow to derive gas exchange parameters for all paranasal sinuses. We report mean gas exchange times for the maxillary, sphenoidal and frontal sinuses as well as the posterior ethmoidal cells obtained from 17 patient studies. Some clinical examples are discussed in detail. Compared to existing procedures, xenon-enhanced dynamic CT is the only non-invasive quantitative method to determine ventilation of all paranasal sinuses.     

Hyperaeration of the frontal sinus

The nasal cavity and paranasal sinuses constitute an anatomical and functional unit. Paranasal sinuses communicate with the nasal cavities, which are covered by the same mucosa, via small openings and narrow ducts that allow both aeration and sinus drainage. Anatomical variations of the paranasal sinuses and nasal cavity are important in sinus diseases. Computerized tomography (CT) plays a critical role in evaluation of the patients with paranasal sinus pathology and variations. A 38-year-old man admitted to our clinic with headache and postnasal dripping for 1 year. His paranasal CT scanning revealed that there is hyperaeration of the frontal sinus which is in continuity with the sphenoid sinus. Hyperaeration of the sinuses may be kept in mind in a patient complaining of headache.     

Allergic fungal sinusitis, fungus ball and invasive sinonasal mycosis - three fungal-related diseases]

BACKGROUND: Three different fungal-related clinical pictures have to be differentiated in the paranasal sinuses: allergic fungal sinusitis, fungus ball and invasive sinonasal mycosis. PURPOSE: A morphological reevaluation of fungal-related diseases of the paranasal sinuses as well as a retrospective analysis of their clinical parameters was performed. PATIENTS AND METHODS: 86 patients with patho-histological proven fungal-related disease of the nasal sinuses were enclosed in this study. Reevaluation and correlation of clinical and histological parameters were conducted on routine material (HE, PAS and Grocott) according to the modern morphological definitions. RESULTS: Invasive sinonasal mycosis was seen in 22 cases, eleven male and eleven female, mean age 57 years (22 to 84 years). It was significantly related (nine out of 22 patients, 41%) to immunocompromising conditions: three patients had diabetes mellitus type II, five had have a radiation therapy due to carcinoma and one patient suffered from bacterial endocarditis. A fungus ball was diagnosed in 60 patients, 26 male, 34 female, mean age 54 years (22-88 years). An immunocompromising condition was seen in nine out of 60 patients (15%). Causes for immune impairment were diabetes mellitus (two patients), radiation therapy due to carcinoma (four patients), myocarditis (one patient) and chronic hepatitis (two patients). Allergic fungal sinusitis was recorded in four patients, three male, one female, mean age 43 years (17-63 years). No immunosuppression was diagnosed. CONCLUSIONS: Despite the fact that allergic fungal sinusitis is the most common fungal disease of the paranasal sinuses, it is not well known among physicians and pathologists and therefore underrepresented within the diagnoses of paranasal infections. The term "aspergilloma" is imprecise and does not represent a clear diagnosis. A further differentiation in "fungus ball" (without invasion) and "invasive sinonasal mycosis" is required. The three groups of fungal-related sinusitis occur at different ages. Allergic fungal sinusitis is common among young adults. An immunocompromising condition is a prerequisite for an invasive sinonasal mycosis.     

Pre- and postoperative sinus penetration of nasal irrigation

Objective/Hypothesis: Endoscopic sinus surgery is an accepted treatment for medically recalcitrant chronic rhinosinusitis. Effective saline douching may improve long‐term outcomes of chronic rhinosinusitis but is often impaired by postoperative ostial stenosis. The aim of this study is to determine a critical ostial size at which douching solution reliably enters the sinus cavities. Study Design: Prospective study of consecutive patient cohort. Methods: Seventeen preoperative or well‐healed postoperative endoscopic sinus surgery patients were irrigated with 5 mL blue food coloring mixed with 200 mL buffered saline from a squeeze bottle. The degree of sinus penetration, sinus ostial patency, and ostial size were endoscopically determined. Results: Sinuses penetrated by blue dye had a significantly larger minimal ostial dimension (7.31 mm; 95% confidence interval 5.54–9.08) than those that had no blue dye penetration (1.26 mm; 95% confidence interval 0.86–1.66) as determined by Student t test. Chi‐square analysis showed that operated sinuses were more likely to be penetrated than nonoperated sinuses (P = .0016) and obstructed sinuses (P = .0325). Logistic regression showed a 95% probability of penetration when the minimum ostial dimension is 3.95 mm or greater. Conclusions: Unoperated sinuses or cases with gross sinus ostial obstruction will not be reliably penetrated by sinus irrigant. A 3.95‐mm ostial diameter seems to be the minimum size to guarantee penetration in paranasal sinuses to maximize the potential for topical sinus treatment.     

Evaluation of nasolacrimal duct function in chronic paranasal sinus infections with 99mTc dacryoscintigraphy]

BACKGROUND: Paranasal sinus infections and nasolacrimal duct obstructions are commonly encountered problems. However the relationship between these two conditions is not yet clear. Trauma, surgery, tumors, and systemic diseases are among the causes of acquired nasolacrimal duct obstructions but most of the cases are idiopathic. In this study patients diagnosed with chronic paranasal sinus infection were examined with 99mTc lacrimal dacryoscintigraphy to assess their nasolacrimal duct function. METHODS: Twenty-four patients diagnosed with chronic paranasal sinus infection are included in the study. These patients were observed for at least three months awaiting surgical treatment following unsuccessful medical treatment. The control group included 16 persons admitted to the ophthalmology department without any nasolacrimal duct disease. Nasal endoscopy and paranasal sinus CT revealed normal findings. The age of the patients with chronic paranasal sinus infection and examined in regard to nasolacrimal duct function was between 15 to 17 with a mean age of 34.2 years. Fourteen patients were male and 10 patients were female. The control group included 9 male and 7 female patients between 18 to 60 years with a mean of 30.5 years. RESULTS: The dacryoscintigraphic examination of 48 nasolacrimal ducts in 24 patients with chronic paranasal sinus infection revealed 7 complete and 18 partial obstructions of the duct, and 23 normal findings. In the control group with 32 nasolacrimal ducts of 16 patients, there was no complete obstruction. Partial obstruction (10.6, 12.0, 14.7 minutes) was be observed in three cases. The statistical workup resulted in a significant difference between paranasal sinus patients and control group (x2 = 15,840 p < 0.001). The paranasal sinus CTs of the patients with paranasal sinus disease were staged using the Lund-Mackay staging system: There is no correlation between the staging score of the paranasal sinus infection and the degree of the obstruction the nasolacrimal duct. CONCLUSION: This study shows that chronic paranasal sinus disease plays an important role in the pathogenesis of nasolacrimal duct obstructions. The presence of infection has an influence on the nasolacrimal drainage system, but the distribution (staging) of the infection does not appear to correlate with the degree of nasolacrimal duct obstruction. Partial obstruction cases that may progress to complete obstruction may be detected by dacryoscintigraphy, and the treatment of chronic paranasal sinus disease may help to overcome the lacrimal drainage problems in these cases.     

Washout of 133-xenon as an objective assessment of paranasal sinus ventilation in endoscopic sinus surgery

Endoscopic sinus surgery (ESS) is today a common method for the treatment of chronic rhinosinusitis. Assessment of the results has been based mainly upon subjective evaluation, and only a few reports present objective measurements. In the present study, the 133-xenon washout technique was used for preoperative and postoperative evaluation of paranasal sinus ventilation in 12 patients selected for ESS. The postoperative half-times (T1/2) of 133-xenon washout were lower in the sinuses with abnormal preoperative half-times (T1/2), especially in the maxillary sinuses, where the postoperative T1/2 was 44 (22 to 150) minutes (median and quartiles, Q1-Q3) as compared with a preoperative T1/2 of 202 (94 to 278) minutes. The postoperative evaluation included a questionnaire and a follow-up visit with endoscopy and measurements of nasal nitric oxide. The results showed that patients who declared a marked reduction in symptoms exhibited significantly improved sinus ventilation. However, no direct correlation was found between improvement in ventilation and symptom improvement. Nine of the 12 patients showed improvement on endoscopy, and these patients also exhibited improved sinus ventilation. The postoperative nasal nitric oxide levels were within the normal range in 11 of the 12 patients; the other patient showed pathological T1/2 values for all paranasal sinuses. The 133-xenon washout technique is thus a method that can be used for objective evaluation of the ventilation of the paranasal sinuses before and after ESS procedures. However, the technique cannot be used to evaluate sinuses with totally obstructed ostia or postoperative sinuses with very wide neoostia, as rapid washout may lead to no activity remaining at the time of measurement.